Health Assessment Final Exam Review

Symptom

Subjective information reported by the patient.

Sign

Objective information observed or measured by the nurse.

Subjective data

What the patient says

Objective data

What the nurse observes or measures during the physical.

What is the purpose of taking a health history?

Describes current and past health state, forming a baseline against which all future changes can be measured. It yields the first nursing diagnoses and is an opportunity to build the patient relationship.

What are the 4 types of patient databases?

• 1. Complete: (Everything/baseline)

• 2. Focused/Problem-Centered: (Focused on one problem)

• 3. Follow-Up: (Recheck a known problem)

• 4. Emergency: (Rapid/crucial information)

What is in the Complete database and why would you use it?

A full health history and physical examination used to establish a baseline and identify current/past health problems.

What is in the Focused/Problem-Centered and why would you use it?

A “mini” database used for one limited or short-term problem, cue complex, or body system.

What is in the Follow-Up and why would you use it?

Used to reassess an identified problem over time and determine whether it is better, worse, or changed, and how the patient is coping.

What is in the Emergency and why would you use it?

A rapid assessment of crucial information while addressing airway, breathing, circulation, level of consciousness, and disability. A complete database can be obtained after the patient is stabilized.

What is included in Past Medical History?

• Childhood illnesses

• Accidents/injuries

• Serious or chronic illnesses

• Hospitalizations

• Operations/surgeries

• Immunizations

• Allergies

  • For allergies, document the allergen AND the patient's reaction and distinguish an actual allergy from a side effect.

• Medications

What is the purpose in Family Medical History?

Shows diseases your patient may be at higher risk for → helps guide early screening + lifestyle changes.

What is included in Family Medical History?

Includes (3 generations):

• Parents

• Grandparents

• Siblings

• Aunts & uncles

• Nieces & nephews

• Cousins

What is documented in Family Medical History?

• Gender (symbols)

• Relationship

• Age

• Health conditions of blood relatives

What are Common conditions to look for in Family Medical History?

• Heart disease

• Hypertension

• Stroke

• Diabetes

• Cancer

• Sickle cell anemia

• Mental illness

• Seizure disorders

• Kidney disease

• Tuberculosis

What are the traps of communication?

1. False reassurance

2. Giving unwanted advice

3. Using authority (“I know best”)

4. Avoidance language

5. Distancing / impersonal speech:

6. Professional jargon

7. Interrupting

8. Biased or leading questions

9. “Why” questions

10. Making assumptions

what is False reassurance

Minimizes the patient’s feelings and blocks honest communication.

How does a nurse use Reflection during an interview?

This echoes the patients’ words to help express meaning.

• The nurse repeats a key phrase the patient said.

• Shows the nurse is listening and understands the patient’s message.

• Encourages the patient to expand, clarify, or go deeper.

• Helps the patient feel heard and supported.

Open-ended Questions are

Allows the patient to give a narrative response. Good for beginning the interview, introducing a new section, or exploring a new topic. (Let the patient tell their story.)

Closed-ended Questions are

Good for obtaining details, completing the ROS, or moving the interview along. When you need specific information.)

What are the techniques and purposes of Inspection?

Using vision and other senses to observe the patient. Look at things such as size, color, shape, symmetry, and abnormalities.

What are the techniques and purposes of Palpation?

(Feel)

• Using the hands and fingers to feel the body. Can be light for surface characteristics or deep for internal structures.

What are the techniques and purposes of Percussion?

Tapping the body to produce sounds that help determine whether underlying tissue contains air/gas, fluid, or solid structures.

What are the techniques and purposes of Auscultation?

(Listen)

• Using a stethoscope to listen to body sounds, such as heart, lung, and bowel sounds.

What are the steps for the techniques?

Inspect → Palpate → Percuss → Auscultate

 Define Chief Complaint

A brief, spontaneous statement in the patient's own words describing why they are seeking care.

Chief Complaint Includes

• One or two symptoms/signs

• Duration

  • Document it in quotation marks when appropriate. Do not turn it into a diagnostic statement.

Define History of Present Illness

(HPI): A detailed, chronological description of the patient’s current problem — starting at onset and tracing the symptom to the present.

• Includes:

  • location,

  • quality,

  • severity,

  • timing,

  • aggravating/relieving factors

  • the patient’s perception of what is happening. 

The 6 HPI Components

• Location

• Character/Quality

• Quantity/Severity

• Timing/Onset

• Aggravating/Relieving Factors

• Patient’s Perception

What is a general survey

It begins at the first encounter with the patient and gives an overall impression of the whole person.

What does a general survey collect

• It includes: 

  • Physical appearance

  • Body structure

  • Mobility

  • Behavior

When is a general survey performed

• At the first encounter

• Before vital signs 

• Before the focused physical exam

• While the patient walks in, sits, talks, or interacts

 Raynaud phenomenon

A vasospastic disorder where cold or stress causes small arteries in the fingers/toes to constrict, leading to color changes:

• (white (ischemia) →

• blue (cyanosis) →

• red (reperfusion), numbness, and tingling. 

Triggers associated to Raynaud phenomenon

cold, stress, vibration, smoking, caffeine

Symptoms of Raynaud phenomenon

coldness, numbness, tingling, burning pain when blood returns 

Primary symptoms of Raynaud phenomenon

idiopathic, more common, milder

Secondary symptoms of Raynaud phenomenon

 associated with autoimmune diseases (scleroderma, lupus) and more severe

Nursing Care considerations for Raynaud phenomenon

• Keep extremities warm

• Assess for ulcers or skin breakdown

• Avoid Triggers

Mechanisms for Lymphedema

The accumulation of protein-rich fluid in interstitial spaces following surgical removal of lymph nodes (e.g., axillary node removal) or radiation therapy. The buildup of proteins further raises local oncotic pressure, pulling in more fluid.

Clinical Presentation for Lymphedema

• Unilateral swelling

• Non-pitting, brawny edema with indurated (hardened) overlaying skin.

* Key Action: Always establish baseline presurgical arm measurements

How to obtain a pulse deficit

Apical Heart Rate - Radial Pulse Rate = Pulse Deficit

• A deficit indicates weak ventricular contractions that fail to push perfusion to the periphery. Frequently seen in atrial fibrillation.

Grading pulses (0-3+ scale)

Grading Scale: 

3+: Increased, Full bounding (Hyperkinetic states)

2+: Normal

1+: Weak, Thready (Shock, PAD)

Where is the Femoral Pulse

below inguinal ligament

Where is the Popliteal Pulse

 curl fingers into popliteal fossa

Where is the Posterior Tibial Pulse

groove behind medial malleolus

Where is the Dorsalis Pedis Pulse

lateral and parallel to extensor tendon of big toe

what causes S1 sound?

Cause: Closure of AV valves (Tricuspid & Mitral)

when does the S1 sound happen?

Beginning of Systole

where would the S1 sound be heard?

Location: Loudest at the Apex

what causes S2 sound?

Cause: Closure of SL valves (Aortic & Pulmonic)

when does the S2 sound happen?

Timing: End of Systole/ Beginning of Diastole

when does the S3 sound happen?

Timing: Early Diastole

when does the S4 sound happen?

Timing: Late Diastole (Just before S1)

where would the S2 sound be heard?

Location: Loudest at the Base

What is the S3 mechanism?

Mechanism: Abnormal ventricular filling. Fluid vibrates as blood collides into a dilated, overfilled ventricle.

What is the S4 mechanism?

Mechanism: Atrial contraction pushes blood into a stiff, noncompliant, or hypertrophic ventricle, creating resistance vibrations

Apical pulse location

located at the 5th intercostal space, midclavicular line (the exact site of the mitral valve). The area where the heart’s beat produces the strongest palpable or visible impulse on the chest wall 

how to assess Point of Maximum Impulse

(Apical pulse)

• located at the 5th intercostal space, midclavicular line

• primarily caused by the apex of the left ventricle as it contracts during systole, pushing against the chest wall

Location of Radial peripheral pulse

located on the thumb side of the wrist, just below the base of the thumb on the palmar side of the forearm.

Location of Brachial peripheral pulse

located on the inner side of the upper arm, just above the elbow crease (antecubital fossa), between the biceps and triceps muscles

Location of Popliteal peripheral pulse

located at the back of the knee, in the midline of the popliteal fossa, over the popliteal artery.

Location of Posterior Tibial peripheral pulse

behind and slightly below the medial malleolus, in the groove between the medial malleolus and Achilles tendon

Location of Dorsalis Pedis peripheral pulse

lateral and parallel to extensor tendon of big toe

What are Murmurs

(Turbulent Flow): Gentle, Swooshing sounds best heard at Erb’s Point

Mnemonic used for Murmurs

S- stenosis

P- Partial Obstruction

A- Aneurysms

M- Mitral Regurgitation

S- Septal Defect

How to auscultate Bruits

Use the bell of the stethoscope and listen over major arteries. (Carotid Artery)

Where to listen for Bruits

• Carotid artery (most common)

• Abdominal aorta

• Renal arteries

• Femoral arteries

What does a Bruit indicate

A whooshing sound caused by turbulent blood flow, usually from narrowing (stenosis) or obstruction

How to auscultate Thrills

Use your palmar surface (flat part of fingers) to feel over the precordium.

Where to listen for Thrills

Over valve areas of the heart (aortic, pulmonic, tricuspid, mitral)

What does a Thrill indicate

A vibration felt on the chest wall — indicates a severe murmur, turbulent blood flow, or significant cardiac abnormality.

How to check for Edema:

Apply pressure to the swollen area for exactly 5 seconds → release → observe indentation.

Pitting Edema Scale:

• 1+ Mild pitting, no perceptible swelling

• 2+ Moderate pitting, subsides rapidly

• 3+ Deep pitting, leg looks swollen

• 4+ Very deep pitting, indentation lasts a long time

Pitting Edema Documentation should include

• Location (e.g., bilateral legs, unilateral ankle)

• Pitting grade (1+ to 4+)

• Whether swelling is bilateral or unilateral

Bilateral Pitting Edema Indicates

Systemic issues (e.g., heart failure)

Unilateral Pitting Edema Indicates

Local obstruction/inflammation (e.g., DVT, lymphedema)

Venous ulcers indicate

Incompetent valves or prior DVTs cause venous blood to pool, increasing pressure and leaking red blood cells into the skin.

Arterial ulcers indicate

Fatty plaques on the intima harden and calcify the arterial wall, starving tissues of oxygen.

Neuropathic ulcers indicate

Generalized nerve dysfunction removes protective sensation, allowing repetitive stress to destroy tissue unnoticed.

Venous ulcers location

Medial malleolus and Tibia

Arterial ulcers location

Toes, Metatarsals, Heels, Lateral Ankle

Neuropathic ulcers location

Plantar aspect of foot, stress/ pressure areas

Venous ulcers s/s

Shallow, weepy, irregular borders, bleeding. Brawny edema, brown pigment (hemosiderin).

Venous ulcers cause

Aching pain in calf/lower leg; worsens with prolonged standing or sitting.

Arterial ulcers s/s

Pale ischemic base, well-defined/ punched-out edges, NO bleeding. Skin is thin, shiny, and cool.

Arterial ulcers cause

Deep muscle pain, claudication; worsens with leg elevation.

Neuropathic ulcers s/s

Surrounding callus, dry skin, poor blood flow

Neuropathic ulcers cause

Numbness, tingling, loss of vibration sensation. Often painless due to nerve damage.

What are the 7 P’s of Neurovascular Assessments?

1. Pain

2. Pallor

3. Pulselessness

4. Paresthesia

5. Paralysis

6. Poikilothermia

7. Pressure

what is Poikilothermia

Inability to regulate temperature; limb feels cold.

what does APE To Man stand for?

A – Aortic

• 2nd intercostal space, right sternal border

P – Pulmonic

• 2nd intercostal space, left sternal border

E – Erb’s Point

• 3rd intercostal space, left sternal border (Bell of the stethoscope)

T – Tricuspid

• 4th intercostal space, left lower sternal border

M – Mitral

• 5th intercostal space, left midclavicular line

What are the 3 normal breath sounds and the location where they are heard?

• Bronchial

  • Location: over the Trachea

• Bronchovesicular

  • Location: over the Bronchial Tree

• Vesicular

  • Location: over the Lung Fields

Bronchial breath sounds like

Loud, high-pitched, hollow

Bronchovesicular breath sounds like

Medium pitch and intensity

Vesicular breath sounds like

soft, low-pitched; louder during inspiration

What are the causes of Asthma

• Bronchoconstriction

• Airway obstruction

• Inflammation

• Response to a trigger

What are the assessments to Asthma

• Wheezing

• Prolonged expiration

• Dyspnea

• Tachycardia

• Use of accessory muscles

• Diminished breath sounds

What are the causes of Pneumonia

Infection of terminal bronchioles and alveoli

What are the assessments to Pneumonia

• Fever

• Malaise

• Pleuritic chest pain

• Crackles

What are the causes of Closed Pneumothorax

• Air in pleural space

• Dyspnea

• Pain

• Tachypnea

• Cyanosis

• Distant breath sounds on affected side

• Decreased chest wall movement

• May have tracheal deviation toward the unaffected side

• Can be spontaneous or traumatic